Healthcare Provider Details

I. General information

NPI: 1871863712
Provider Name (Legal Business Name): KAY B ROCHESTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SE 4TH ST SUITE H
MOORE OK
73160-7329
US

IV. Provider business mailing address

1400 SE 4TH ST SUITE H
MOORE OK
73160-7329
US

V. Phone/Fax

Practice location:
  • Phone: 405-799-7400
  • Fax:
Mailing address:
  • Phone: 405-799-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2081
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: